CTO Revascularization in 2015

Jeffrey W. Moses, MD

Professor of Medicine

Director, Interventional Cardiac Therapeutics

Columbia University Medical Center

Director Complex Coronary Interventions

St. Francis Hospital, Roslyn, LI

Disclosure Statement of

Financial Interest

I, Jeffrey W. Moses, MD am a consultant

to BSC ,Abbott,Medtronic (minor)

False Assumptions about Coronary Chronic

Total Occlusions

• The CTO is well collateralized and

therefore there is minimal impact on

quality of life and prognosis

• CTO is a closed vessel and therefore

not at risk for/or during ACS/AMI

• CTO outcomes are more benign than

non CTO coronary disease

National Attempt Rates

ACC-NCDR

13.6

11.712.4 11.8

0

5

10

15

20

2004^ 2005 2006 2007*

National Attempt Rate Over Time

* Through Q3

^ Jan 1 2004-Mar 31 2005

Courtesy J Aaron Grantham and ACC/NCDR

Clinical Indications Why Open a Chronically Occluded Coronary Artery?

• Symptom control

Angina

CHF

Fatigue

• Improve LV function

Regional

Global

• Survival

Improved tolerance of AMI

Complete revascularization

Ischemic Risk

Collaterals are Usually not Sufficient to

Substantially Reduce Ischemia in CTO

Modified from Werner GS et al, European Heart Journal 2006,

courtesy Werner GS

Evidence for Quality of Life Benefit

Effect of Procedural Success

- 40 - 20 0 20 40

SAQ Quality of Life

SAQ Physical Limitation

SAQ Angina Frequency

Symptomatic

SAQ Quality of Life

SAQ Physical Limitation

SAQ Angina Frequency

Asymptomatic

27 . 3 ( 16 . 5 , 38 . 0 )

15 . 9 ( 5 . 1 , 26 . 7 )

10 . 3 ( - 0 . 8 , 21 . 3 )

8 . 5 ( - 3 . 7 , 20 . 7 )

6 . 3 ( - 5 . 0 , 17 . 6 )

4 . 3 ( - 5 . 4 , 13 . 9 )

125 pts completed the Seattle Angina Questionnaire (SAQ) before and one

month after PCI. 69 procedural success (55%), 56 failures (45%)

Grantham JA. et al, Circulation: QCOR 2010;3:284-90

Impact of Successful CTO-PCI: Angina Long-term angina benefit favors CTO-PCI success

Angioi, et al.

Drozd, et. al.

Finci, et. al.

Ivanhoe, et. al.

Olivari, et. al.

Warren, et. al.

Total (n=1030)

Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010.

Impact of Successful CTO-PCI: Mortality Long-term survival benefit favors CTO-PCI success

Joyal D, Afilalo J, Rinfret S. Am Heart J, 2010.

0.0%

15.6%

22.3%

39.3%

0%

10%

20%

30%

40%

Death

or

MI

Rate

(%

)

COURAGE

Rates of Death or MI by Residual Ischemia

p=0.002

0%

(n=23)

p=0.023

p=0.063

1%-4.9%

(n=141)

5%-9.9%

(n=88)

>10%

(n=62)

Shaw et al, Circ 2008;117

Residual SYNTAX Score in SYNTAX

Trial

Low Baseline SYNTAX Score (0-22) Intermediate Baseline SYNTAX Score (23-32) High Baseline SYNTAX Score (≥33)

Es

tim

ate

d E

ve

nt

Ra

te

All-Cause Death (y)

Residual

SYNTAX Score Log–rank

P value .022

23.8%

13.8%

7.7% 6.7%

0

>0–4

>4–8

>8

60%

50%

40%

30%

20%

10%

0%

0 1 2 3 4 5

All-Cause Death (y)

Log–rank

P value <.001

34.1%

12.9% 10.1% 8.2%

60%

50%

40%

30%

20%

10%

0%

0 1 2 3 4 5

All-Cause Death (y)

Log–rank

P value <.001

39.1%

11.5%

10.2% 9.3%

60%

50%

40%

30%

20%

10%

0%

0 1 2 3 4 5

Kereiakes et al, Rev Cardiovasc Med. 2014;15:24-30

Farooq Circ 2013;128:141

Material and Methods • Retrospective analysis of coronary

angiography performed with regard to

procedure details and angiographic

completeness of revascularization

• Complete angiographic

revascularization defined as:

– No angiographically significant

stenosis in all vessels with

diameter of at least 2mm

– Significant stenosis

defined as: LM and

proximal LAD ≥ 50%

MLD and ≥70% in all

other arteries

Results

12 Months

Variable (%)

Complete revasc

(n=222)

Incomplete revasc

(n=217) P value

Myocardial infarction 2,3% 5,5% 0,125

All-cause mortality 10,4% 18,4% 0,01

Death or MI 11,7% 23,5% 0,002

Aorta-PD graft

Retrograde Approach

Transit™

Fielder

CTO Crossing Successful strategy

2.2%

56.9%30.7%

10.1%Retrograde

Wire Cross

Kissing Wire

Technique

Reverse

CART

CART

~ 90%

Reverse CART

Courtesy of Dr. Masahiko Ochiai

Reverse CART

3.0mm rx antegrade

Corsair

Reverse CART Distal cap access

Advance corsair into antegrade guide

Exchange for viper wire

Trap prn

IVUS Guided Identification of the Entry

IVUS Guided Technique

for Looking For the Entry

IVUS in LA branch

CTO

*

Where is the origin?

Complex CTO

of MLCX

The Stingray™ CTO Re-Entry System

Unique self-orienting

balloon has a flat shape for

true lumen targeting

180° opposed and offset

exit ports for selective

guidewire re-entry

Re-entry probe at

Stingray

Guidewire tip

Compatibility:

Coronary: 0.014” Wire

The StingRay™ System (Catheter and Guidewire) is

designed to accurately target and re-enter the true lumen

from a subintimal position.

• Multi-wire coiled shaft

• Tracks via FAST Spin Technique

– Highly torqueable coiled-wire shaft

– FAST Spin reduces push required to cross CTO

• Atraumatic distal tip advanced across a CTO ahead of the guidewire

• OTW 0.014” guidewire compatible

The CrossBoss™ CTO Crossing

Catheter The CrossBoss™ catheter is an OTW stainless steel

catheter designed to quickly and safely pass through the

CTO to gain access to the distal true lumen or enter

subintimal pathways. The catheter is advanced by using

rapid bi-directional rotation.

Ratchet Handle for

FAST-Spin Technique

Atraumatic 1 mm

Distal Tip

Brilakis et al.

Hybrid Strategy Treatment Algorithm

Antegrade Paradigm

• 48 year old man with hypertension,

hyperlipidemia, known coronary artery disease

3 months prior to admission presented to

outside hospital with acute chest pain, STEMI,

and underwent thrombus aspiration and PCI to

RCA

LAD CTO intervention attempted but

abandoned due to vessel perforation

Continued to have exertional chest pain, so he

was referred to Columbia for second opinion

Dual Injection

Antegrade – Crossing the lesion

• Corsair

• Attempted wires: Asahi Gaia 1, 2, 3

• Confianza Pro 12 used to pierce

• Gaia 2 used to cross lesion

Confienza

Corsair Tip In

Gaia 2nd Advancing

Aligning

Crossing

In Distal Vessel

LAD lesion prep

• Gaia exchanged for

BMW wire

• Corsair removed with

trapping balloon

• Mid-LAD dilated with

NC 2.5 and 3.0 x 8mm

balloons

Final picture

Typical Retrograde Wire Sequence

• 78 year old man with hypertension, prior tobacco use,

prostate cancer, carotid stenosis and coronary artery

disease

1987: Cardiac catheterization via brachial approach in

with PTCA to unknown vessel complicated by

endocarditis

2014: Presented with one month of worsening exertional

chest pain to outside hospital

Echocardiogram: normal systolic function, no wall

motion or valvular abnormalities

Coronary angiogram: complex multi-vessel disease

including chronic total occlusion of the PDA for which

he was transferred to Columbia-Presbyterian

Initial dual injection

8F bright-tip sheaths

8F JR4

5F diagnostic JL4

Left coronary intervention

• 7F FL 4.0 Guide for antegrade left coronary

intervention

• BMW, Prowater wires

• Angiosculpt 3 x 10mm in left main 18atm

• NC 3 x 12mm balloon in mid LAD

Left coronary intervention

• Premier 3 x 12mm stent in LAD

• Premier 4 x 8mm stent in LM

• NC 4.5 x 8mm in LM stent post-dilation

• IVUS

• NC 4 x 8mm post-dilate

Retrograde RCA CTO Intervention

• 150cm Corsair

• Prowater used to access septal collaterals

• Sion wire for collateral surfing, successfully

accessed RPDA

Setup for reverse CART

• Miracle 6 in corsair antegrade

• Pilot 200 retrograde

Retrograde RCA CTO Intervention

• 2.5 x 30 balloon in distal RCA

• 8F Guideliner entered with Confienza Pro

12 and exchanged for Viper wire

• Resolute 2.5 x 30mm stent in distal RCA

• Resolute 3 x 38mm stent in mid RCA

• Resolute 3.5 x 22mm stent in proximal RCA

RCA stents

Final pictures

Antegrade Dissection Reentry

J-CTO Score Sheet

Morino Y et al. JACC Interv, 2011;4: 213-221

Predicting Success: The J-CTO Score

Morino Y et al. JACC Interv, 2011;4:213-221

Fin

al G

W s

uc

cess,

%

Risk groups:

J-CTO Score: 1 0 2 >=3

Patient number 130 494 138 135 91

Easy Intermediate Difficult Very difficult

73.3

88.4 92.3 97.8

>90 min

60-90 min

30-60 min

=<30 min

100

90

80

70

60

50

40

30

20

10 0

Revascularization for CTO

Conclusions

• CTOs negatively impact our patients quality

of life as well as prognosis

• Patients with symptoms, multivessel CAD,

and moderate to large CTO-mediated

ischemic burden derive clinical benefit

• We under treat these patients

• Great opportunity exists to benefit public

health by expanding CTO revascularization